Week 4 | Venous Ulcers (16180-SP)

Photo of lower leg with injury.

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How Big Is the Problem of Lower Extremity Ulcers?

  • 2% population will develop poorly healing ulcer
  • Prevalence increases with age
  • Causes many days lost work
  • Costs up to $40,000.00 for long-term treatment
  • Causes considerable clinical issues- Exudate, Changes in limb sizes, Altered shape of leg, Odor, Discomfort

Impact to the Person

  • Long term management difficult (compliance, recurrence)
  • Economic impact (treatments, lost work)

Types of Lower Leg Ulcers

  • Venous ulcers
  • Arterial/ischemic ulcers
  • Combined venous/arterial
    • Others

Normal Venous Anatomy Components

  • Deep venous system (accompany arteries, same name, have valves)
    • Femoral
    • Popliteal
    • Tibial 
  • Superficial venous system (just below skin, have valves)
    • Greater saphenous
    • Lesser saphenous
  • Perforator Veins (connect the 2, have valves)

Need for Orthograde Flow

  • Competent valves
  • Calf muscle contraction
  • Venous wall condition

Anatomy/Physiology Venous Disease

  • Impeded venous return to the heart
  • Incompetent, mal-functioning valves
  • Results
    • Edema
    • Hemosiderin staining, skin changes
    • Fibrin bands constrict capillaries - results in decreased oxygen and nutrients to area

Assessment of the Patient

  • Determine patient history and risk factors
  • Conduct brief physical exam, including lower extremities
  • Assess vascular status
  • Determine ulcer status and duration
  • Discuss patient’s understanding of ulcer and treatment
  • Identify prior treatment
  • Inquire about patient support network

Contributing Factors to Venous Ulcers

  • Deep vein thrombosis
  • Congestive heart failure
  • Obesity
  • Pregnancy
  • Trauma to lower leg
  • Incompetent valves
  • Weakness of lower extremity musculature
  • Thrombophilic conditions (Factor V, Protein C or S)

Chronic Venous Insufficiency

  • Progressive primary reflux disease secondary to varicose veins – 1/3 to1/2
  • Others follow a DVT – 1/3 cases

Clinical Signs with Ulceration

  • Hemosiderosis/ Hyperpigmentation
  • Edema
  • Lipodermatosclerosis
  • Atrophie Blanche
  • Venous Dermatitis
  • Ankle Flare
  • Ulceration with Serpiginous Edges
  • Hemosiderin Staining – factor in skin changes
  • Edema - Appearance
  • Lipodermatosclerosis – “Hardening”
  • Atrophie Blanche
  • Venous Dermatitis
  • Ankle Flare
  • Wounds With Serpiginous Edges

Principles of Management

  • Compression provides the most dramatic effect on wound closure
    • Decreased pain
    • Increased mobility
    • Improved quality of life
    • External compression increases local tissue pressure, reinforces reabsorption by squeezing fluid into venous and lymph system.
    • Determine if arterial disease is present.
    • Practice safely for your patient.
    • Measure Ankle-Brachial Index (ABI) before you proceed.

Objectives for Learning Outcomes

After completing this session, you will be able to:

  1. Discuss how venous ulcers happen. 
  2. Assess the client with venous ulcers. 
  3. Identify characteristics seen in the patient with venous ulcers. 
  4. Individualize an appropriate plan of care for the venous ulcer patient. 
  5. Determine when to refer the patient with mixed disease ulcers.
Course summary

Certified Wound Care Nurse; Co-Director, Wound Management Education Program (WMEP) and Wound Management Fundamentals Course (WMFC), Continuing Nursing Education, University of Washington School of Nursing, Seattle; Fellow, College of Certified Wound Specialists

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